Disclosure. Thank you! Function. Cont - Role 12/2/2014. Role as a Nurse Practitioner in DM Clinic at MLK Jr., OC

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1 How to Use Midlevel Providers Effectively Disclosure I have no relevant financial relationship to disclose Maria Navar, MSN, FNP-C, CDE Thank you! To Dr. Friedman for giving us this opportunity! Kaiser Permanente and UCLA CTSI for the financial support for this event to be a reality Role as a Nurse Practitioner in DM Clinic at MLK Jr., OC Work autonomously at assessing, diagnosing, managing, treating, and following patients with diabetes and the co-related chronic diseases that accompany diabetes Follow Dr. Mayer Davidson s approved detailed treatment algorithms for diabetes, hypertension, and dyslipidemia Cont - Role Provide *education to patients and their families Provide high quality patient care Improving patient outcomes **HbA1c, BP, Lipids Improve patient satisfaction*** Cost effective****(decrease U/C visits, decrease hospitalization, preventive care) Function Educator educate patients and their families: difference btw type 1 and type 2 diabetes, risk of DM - *(Myths) pathophysiology of disease, medications orals (how they work and when to take) insulin** (when it works and when to inject) s/s of hypo/hyper and what to do? complications, sick days 1

2 Continue Function/Educator importance of exercise, diet/nutrition (weight management), smoking cessation, stress management * meeting the psychosocial needs of the pt. (depression) individualized treatment** Self monitoring of BG on multiple shots of insulin check BG alternating*** Cont Education is a time consuming process a comprehensive class can not be done in one visit Focus on their particular 1-2 issues at each visit, but on every visit make sure to teach Avoid using medical jargon - poorly educated minority population (some patients can not read or write) EDUCATION: Empowers the patients and their families it gives patients the ability to participate in disease self management and have control of their disease/s MLK Jr., OC - Diabetes Clinic In our clinic each provider has nine sessions per week frequency of visits or interactions depend on the treatment/control of patients (orals alone, combination of orals and insulin, or insulin alone)* Comprehensive Diabetes clinic F/U every 3 to 4 months** New patients in our clinic, are scheduled for classes*** We follow btw patients**** Cont HbA1c results from the lab, reported monthly but requested every 3 4 months on all patients; our results show: < 7.0% = 33% (1/3 of patients) < 7.5% = 50% < 8.0% = 66% (2/3 of patients) > 9.0% = ~ 15% = Mostly based on new patients or non adherent to treatment recommendations or f/u * Thank you!! 50% of all our patients are on insulin** 2

3 Diabetes Case Management Disclosure Loretta Ball NP-C, CDE, BC-ADM I HAVE NO RELEVANT FINANCIAL RELATIONSHIP TO DISCLOSE Diabetes Education and Clinical Program Inpatient Diabetes Education Nia Bakewell RN, CDE Socorro Marquez-Torres RN Diabetes Case Management Jose Mendoza RN, CDE Loretta Ball NP-C, CDE, BC-ADM Diabetes DMP Juan Olmos RN, CDE Noemi Capistrano NP-C, CDE Components of Diabetes Management Program Diabetes Education Classes 1-to-1 Teaching For Insulin Administration Case Management Diabetes Education Classes Referrals For Case Management General Facts Exercise Hypoglycemia Nutrition Medication Self Blood Glucose Monitoring Foot Care Complications Sick Days Hyperglycemia Stress Must complete pink referral form Current A1c ( >8 ) Eye status Outcome desired (glycemic & other goals) Hypoglycemia? Current phone number 3

4 Diabetes Case Management Identify barriers to compliance Application of theory learned in class Frequent insulin adjustment Carbohydrate counting Interpretation of lab results Poly-pharmacy Goal setting Grad program Barriers To Education Language Barriers Low Literacy Skills Health Beliefs/Cultural Beliefs Self-Efficacy/Empowerment Readiness To Change Emotional Well-Being Substance Abuse Steps For Facilitating Empowerment Start with the patient s agenda Work to individualize treatment plan Step by step approach Facilitate problem solving skills Use contracts / goal setting Involve family and significant others Nourish emotional coping skills Current Goals For Case Management A1c < 7.0 LDL < 100 Blood Pressure < 140/80 Psychosocial Goals For Case Management Pre-Screening For Depression PHQ-9 Depression Questionnaire Evaluation by Dr. Kaplan Diabetes Clinic Social Worker: Referrals for follow up Community Mental Heath Clinic Antidepressant Medication Accord and Advance Trials Need for individualized A1c targets for high risk patients History of cardiovascular events CKD or ESRD Age and duration of diabetes Microvascular complications 4

5 Possible Early Worsening of Diabetic Retinopathy Retrospective study by Dr. Ana Shurter Patients with moderate to severe retinopathy may have increased risk. Benefit to decreasing A1c gradually Case management needed to ensure A1c doesn t drop too quickly Repeat eye photos at shorter time interval Prevent Progression of Microalbuminuria ACE or ARB Therapy Monthly albumin/creatinine ratios Adjust ACE/ARB at 1-2 week intervals Monitor Blood Pressure Check K+ and Creatinine 5-7 days after each dose change Low potassium diet / kayexalate prn Management of Hyperlipidemia Hypertriglyceridemia Diabetes Case Management: Statistical Analysis Monthly medication dosage adjustments Medical Nutrition Therapy Monthly lipid levels Addition of Fenofibrate/Niacin with statin Frequent monitoring of hepatic function Monitor CK if symptomatic 213 Case Management Graduates (pre-existing diabetes clinic program) Blood Pressure 97 males 116 females Average Age: 44.9 years Pediatric Patients: 5 New Diagnosis of Diabetes: 55 Average Duration of Diabetes: 11.8 years Average Time in Program: 5.9 months A1c Starting Ending LDL Starting Ending Average at Start Average at Graduation 129 systolic 123 systolic 73 diastolic 71 diastolic 5

6 Nurse Diabetes Health Care Outcomes THANK YOU! Maria Blanco Castellanos, R.N. C.D.E. Latino Community Diabetes Council Disclosure I have no financial interest to disclose STUDY PROTOCOL Los Angeles County Community Clinic Poor, poorly educated, mostly uninsured population Patients randomly selected from adult clinics Nurse followed detailed algorithms and supervised by an endocrinologist Endocrinologist met with nurse once per week and was available by phone Patients followed for one year DEMOGRAPHICS Number of Patients 367 Age 51.2 ± 10.6 years Disease Duration 6.9 ± 6.6 years Females 71% Race/Ethnicity African-American - 80 (22%) Caucasian - 2 (0.5%) Latino (77%) Asian - 2 (0.5%) Type 1 diabetes 2 (0.5%) Type 2 diabetes 365 (99.5) EDUCATION AND INCOME LEVELS Subset of Latino patients (137/283) queried Education (n=102) 73% had 6 th grade or less Household Income (n=63) 95% <$25,000 6

7 FINAL TREATMENTS Usual Care (Prior Year) Nurse-Directed Care Number of patients P Value (Chi square) Diet only 14 (4%) 9 (2%) NS One oral drug 108 (33%) 71(19%) < Oral drugs 145 (44%) 193 (53%) <0.025 One insulin injection 2 (1%) 1 (1%) NS Bedtime insulin* 47 (14%) 85 (23%) <0.01 OUTCOME MEASURES (Hb A1C - %) Usual Care* (n=303) Nurse-Directed Care (n=364) + P Value Initial 9.3 ± ± 2.5 <0.001 Final 8.7 ± ± 1.3 <0.001 Change -0.6 ± ± 2.6 <0.001 P Value <0.001 < *plus Insulin oral drugs injections 15 (4%) 8 (2%) NS *Prior year + 3 patients had hemoglobinopathies n= 361 (3 patients had only one test) OUTCOME MEASURES (Hb A1C Percent meeting goal of <7.0%) Usual Care* (n=303) Nurse- Directed Care (n=361) P Value Initial 17% 28% <0.001 Final 28% 59% <0.001 P value <0.001 <0.001 * Prior year OUTCOME MEASURES (LDL Cholesterol Percent meeting goal*) Usual Care* (n=244) Nurse- Directed Care (n=366) *Goal <130 mg/dl in year 1 and <100 mg/dl in years 2 and patients had at least 2 values P Value Initial 51% 50% NS Final 50% 82% <0.001 P value NS <0.001 PREVENTABLE DIABETES-RELATED URGENT CARE (UC) AND EMERGENCY ROOM (ER) VISITS/HOSPITALIZATIONS (HOSP) Year Prior Nurse-Directed Care UC/ER 15 4 Hosp 6 1 Total % reduction (P <0.001) Charges $129,176 $24,630 7

8 TREATMENTS Initial Final Number of patients 178 One oral drug 7 (4%) 9 (6%) 2 oral drugs 60 (34%) 18 (10%) Bedtime insulin* 44 (25%) 15 (8%) 2 Insulin injections 53 (30%) 132 (74%) Premixed insulin 14 (8%) 4 (2%) *plus oral drugs CARVE IN MODEL RESULTS A1C LEVELS (Mean ± SD) Initial 11.1% ± 2.3 Final 7.2% ± 0.9 Delta % ± 2.5 N = 178 patients; 74% on split-mixed and 8% on bedtime insulin after ~10 months of RN nurse directed diabetes care (Am J Manag Care 16: , 2010) CARVE IN MODEL RESULTS (PERCENT ACHIEVING TARGETS) Measure (Target) Baseline Final P Value Hb A1c (<7.0%) 0%* 49% - LDL Chol (<100 mg/dl) 43% 96% <0.001 Triglyceride (<150 mg/dl) 55% 83% <0.001 Systolic BP (<130 mm Hg) 43% 90% <0.001 Diastolic BP (<80 mm Hg) 77% 95% <0.001 Hb A1c Outcomes of Nurse Following Treatment Algorithms for One Year in a Minority Population* (~75% Latinos, 25% African-Americans) Study #1 (N = 367 randomized patients) Hb A1c levels fell from 8.9% to 7.0% (25% ended up on insulin mostly bedtime alone) Study #2 (N = 178 referred patients) Hb A1c levels fell from 11.1% to 7.2% (83% ended up on insulin mostly 2 injections) *A1C >8.0% required for referral McNemar s test *Davidson et al: Am J Manag Care16: , 2010 PERCENT ACHIEVING A1C (<7.0%), LDL CHOL (<100 MG/DL) AND BP (<130/80 MM HG) GOALS Year (Ref) N Setting Percent 2002 (1) 1,372 Two Urban Medical Centers (2) 1,218 NHANES III (2) 404 NHANES (3) 1,765 Academic Medical Centers (4) 439 Population Survey - Australia (5) 7,120 Academic Hospitals (6) 395 Endocrine Practices (7) 3,131; 3,971* Primary Care Practices 8.5; 12.6* 2009 (8) 1,694 NHANES (9) 511 Primary Care Practices (10) 178 Community Clinic Minorities (11) 1,343 NHANES * Chronic Care Model: 1 Diabetes Care (DC) 25:718; 2 JAMA 291:335; 3 DC 28:337; 4 DC 28:1490; 5 DC 30:1442; 6 Diab Res Clin Pract 80:89; 7 DC 31:2238; 8 Am J Med 122:443; 9 CMAJ 181:37; 10 Am J Manag Care 16:652; 11 DC 36:2271 KEY COMPONENTS FOR GOOD DIABETES CARE Knowledgeable provider Time to interact with patient Communication with patient Educated patient Patient s ability to carry out treatment recommendations Nurses following protocols under appropriate supervision do it better! 8

9 Diabetes can be Controlled Committed Team Culturally Sensitive Care Patient Education ADA Adherence Ongoing Monitoring Treatment Labs Our mission is to provide diabetes education, advocacy, and resources for people with diabetes. Join Us! Latino Community Diabetes Council Beverly Boulevard, Suite A5-184 Whittier, California Board Members Albert Tovar, President Esther Elias-Ramirez, Vice President Marie Lizarraga, Treasurer Maria Castellanos, RN, CDE Nancy Damiani, MPH, RD Diana Nancy De León, MPH Sergio Villegas, MD Thank you! On behalf of all of us (midlevel providers - NPs, PAs, RNs, and Pharmacists) that have been under the wings of Dr. Mayer Davidson and Dr. Eli Ipp mentored and following their algorithms We would like to say: THANK YOU DR. DAVIDSON and Dr. IPP Questions? For your visionaries and constant support! 9